With Active Surveillance on the rise, one would think that doctors who support AS for their prostate cancer patients have similar commitment and protocols. A new study (Sep. 2016) in the British Journal of Urology International (BJUI) spells out 8 areas of qualitative differences among AS doctors:
- physician comfort with active surveillance
- protocol selection
- beliefs about the utility and quality of testing
- years of experience and exposure to AS during training
- concerns about inflicting “harm”
- patient characteristics
- patient preferences
- financial incentives[i]
The authors state that these factors influence MD decisions in managing AS patients. Currently, there is no universal agreement on AS protocol. Many doctors seek precedents or recommendations set by such institutions as Johns Hopkins, or guidelines from organizations like the National Comprehensive Cancer Network (NCCN). Given the 8 areas, there is clearly variance in how doctors work with their AS patients.
I want to use this study to share our Center’s AS approach and philosophy in the 8 areas:
- Physician comfort: There is no question of our comfort level with AS because of our superior use of 3T multiparametric MRI for both qualifying and monitoring patients. For example, if a urologist refers a patient who has had TRUS biopsy-demonstrated Gleason 3+3 PCa to us for imaging, the initial mpMRI scan becomes a baseline for future comparison, and also reveals any area suspicious for Gleason 4 (or significant) PCa before starting AS. If so, we can do an in-bore targeted biopsy, and then collaborate with the referring physician in discussing options with the patient. On the other hand, if the baseline mpMRI confirms low risk, we are confident in the patient’s candidacy for AS, and our report back to the referring MD confirms this.
- Protocol selection: Whether the patient is referred to us, or finds us on his own, we favor an individualized protocol over standardized. Each person’s PCa is as unique as that individual. Research shows that PSA testing at regular intervals, coupled with an annual mpMRI or a scan triggered by a rise in PSA, gives a high degree of confidence that signs of tumor growth or progression will be detected early enough to avert danger.
- Beliefs about the utility/quality of testing: We believe that 3T mpMRI integrated with PSA tests, and reinforced by genomic testing as necessary, is the best available AS monitoring, and helps avoid unnecessary repeat biopsies.
- Years of experience/training: Our Center has performed thousands of mpMRI scans for the detection, diagnosis and image guidance of Focal Laser Ablation (FLA), so our patients and colleagues are assured of our experience. As far as training, urologists generally have more exposure to AS during training, though often limited; however, AS standards are ever-changing as new research reveals previously unrecognized PCa aspects, so all of us who deal with PCa must continually revise our knowledge of how to administer AS. This is another reason why high resolution imaging is so important for qualifying and monitoring patients. Information and theories may change, but a picture shows the reality.
- Concerns about “harm”: With AS, there is an ever-present risk of missing a harmful PCa change. Take the case of a Gleason 3+3 patient who has been on AS for almost three years. He has never had an mpMRI, only PSA tests every 6 months, and a repeat biopsy at the end of his first year that found no change. He and his urologist agreed he did not need a biopsy at the end of year 2 because his PSA was stable at 5.7. Then, a PSA 6 months later registers 6.1, and his doctor recommends a 12-core TRUS biopsy. One needle comes back with Gleason 4+3, and the doctor suggests it’s time for treatment. By all clinical signs—but still no imaging—the patient is a candidate for nerve-sparing robotic prostatectomy, which he chooses to have. The final pathology reveals the tumor penetrated the margin, so the surgeon recommends a course of radiation to the pelvic bed. Perhaps we could have helped avoid this scenario, since an annual 3T mpMRI would have 95-98% probability of picking up progression to Gleason 4+3 sooner, and also show the encroachment on the prostate capsule. It could have made a difference.
- Patient characteristics: mpMRI provides a “portrait” of the tumor which, when integrated with all other clinical factors, reveals if this person is a strong candidate for AS. Another important characteristic is how psychologically suited a person is, since some patients are made anxious at the idea of PCa growing in their body. Others may not be suited for strict compliance with their doctor’s AS protocol, in which case they would be unwittingly putting themselves at risk. We always discuss the psychology of AS as well as go over a patient’s images with him.
- Patient preferences: We wholeheartedly agree that what’s important to each person must be taken into account in choosing and staying with AS. Each man’s lifestyle, age, relationships, beliefs and other factors affect how important it is for him to choose AS over treatment.
- Financial incentives: Doctors certainly want what’s best for their patients, and because most urologists were taught that PCa is a multifocal disease, they are not comfortable with the idea of leaving cancer to take its own course when they can’t literally keep an eye on it since they don’t offer mpMRI. Then there’s the reality that maintaining a patient on AS brings little income to their practice. Thus, many urologists are biased toward getting patients into treatment both philosophically and financially. Since our Center provides mpMRI, which we know to be an essential adjunct to successful AS, we are not in the same situation. Our imaging provides back-up for a patient’s AS as long as the patient wants it, and it is safe to do so.
A word about Focal Laser Ablation
Focal therapy is widely recognized as a rational middle ground between AS and whole gland treatments (surgery, radiation). Thanks to 3T mpMRI and in-bore targeted biopsy, as well as PSA and genomic biomarkers, we can identify not only candidates for AS but also for the focal therapy of their choice. For thousands of men, a focal ablation (destruction) of a significant PCa tumor accomplishes two desirable outcomes:
- Controlling PCa in a way that AS cannot accomplish, therefore offering peace of mind while gentle mpMRI-and-PSA monitoring continue, and
- Avoiding whole gland treatment, with its risks of side effects.
Our Center specializes in Focal Laser Ablation (FLA) which is exquisitely precise and able to be monitored during and immediately after treatment. Patients walk out the door after treatment, with no risk of incontinence and minimal-to-zero risk of ED. We are proud that being the most experienced in FLA has made us the recognized leaders.
We are happy that there is growing recognition of AS as an alternative to immediate whole gland treatment with its risk of side effects. We are also well aware of two important studies since the USPSTF issued its recommendations against routine PSA screenings in order to avoid overdetection and overtreatment; both studies showed a decrease in the overall numbers of men diagnosed with PCa, but an increase in the diagnosis of higher risk (Gleason 4+3) disease. In the face of this evidence, we believe more than ever in focal therapy for qualified patients, and we have the means to identify who they are. For men who want to hold off on treatment but don’t like the idea of active PCa putting them in harm’s way, our Center offers FLA as an option that keeps PCa in check, but keeps all future treatment options (including repeat FLA) open should that become necessary.
I believe that the Sperling Prostate Center for mpMRI-based detection, diagnosis and treatment of prostate cancer offers the excellence in care that patients want and deserve. We constantly strive to maintain the highest standards of care. The Sperling Prostate Center gives AS patients the peace of mind they seek.
[i] Loeb S, Curnyn C, Fagerlin A, Braithwaite R et al. Qualitative study on decision-making by prostate cancer physicians during active surveillance. BJU Int. 2016 Sep 9. doi: 10.1111/bju.13651. [Epub ahead of print]